Hindawi Publishing CorporationJournal of Aging ResearchVolume 2012, Article ID 306818, 30 pagesdoi:10.1155/2012/306818

Review Article

Flexibility Training and Functional Ability in Older Adults:A Systematic Review

Liza Stathokostas,1 Robert M. D. Little,1 A. A. Vandervoort,2 and Donald H. Paterson1

1 Canadian Centre for Activity and Aging, School of Kinesiology, The University of Western Ontario, London, 3M Centre 2225,ON, Canada N6A 3K7

2 School of Physical Therapy, Elborn College 1400, The University of Western Ontario, London, ON, Canada N6A 3K7

Correspondence should be addressed to Liza Stathokostas, lstatho2@uwo.ca

Received 9 July 2012; Accepted 11 September 2012

Academic Editor: Wojtek Chodzko-Zajko

Copyright © 2012 Liza Stathokostas et al. This is an open access article distributed under the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properlycited.

Background. As indicated in a recent systematic review relating to Canada’s Physical Activity Guidelines for Older Adults,exercise interventions in older adults can maintain or improve functional abilities. Less is known about the role of flexibilityin the maintenance or improvement of functional abilities, and there currently does not exist a synthesis of the literaturesupporting a consensus on flexibility training prescription. Purpose. To systematically review the effects of flexibility-specifictraining interventions on measures of functional outcomes in healthy older adults over the age of 65 years. Methods. Five electronicdatabases were searched for intervention studies involving concepts related to aging, flexibility, functional outcomes, and traininginterventions. After evaluating the articles for relevance, 22 studies were considered. Results. The results suggested that whileflexibility-specific interventions may have effects on range of motion (ROM) outcomes, there is conflicting information regardingboth the relationship between flexibility interventions and functional outcomes or daily functioning. Conclusions. Due to thewide range of intervention protocols, body parts studied, and functional measurements, conclusive recommendations regardingflexibility training for older adults or the validity of flexibility training interventions as supplements to other forms of exercise, oras significant positive influences on functional ability, require further investigation.

1. Introduction

As indicated in a recent systematic review relating toCanada’s Physical Activity Guidelines for Older Adults,exercise interventions (comprised of aerobic and strengthtraining) in older adults can maintain or improve functionalabilities [1]. Less is known about the role of flexibility inthe maintenance or improvement of functional abilities.While joint flexibility may decrease with age, with thepotential to affect normal daily function, older adults domaintain the ability to improve flexibility through stretchingexercises [1]. The 2009 American College of Sports Medicine(ACSM) position statement “Exercise and Physical Activityfor Older Adults” [2] noted there is a lack of studiesof the effects of range of motion exercises on flexibilityoutcomes in older populations and a lack of consensusregarding the prescription of stretching exercises for olderadults. Despite the lack of a synthesis of the literature to

support the recommendation of the inclusion of a flexibilitycomponent to older adult exercise programs, many olderadult activity programs place a considerable emphasis onflexibility. Stretching exercises are used extensively in therehabilitation context wherein injury or disease may haveresulted in a restricted range of motion specific to givenjoints, and the goal is to regain “normal” range of motion[3]. However, the present paper is focused not on stretchingexercise for rehabilitation purposes but for the role offlexibility in general exercise prescription for older adults.

In light of the significant benefits of an exercise programfor an aging population, it is important to provide evidence-based prescription for older adult exercise programs andhighlight areas of research requiring further investigation inorder to maximize these benefits. The goal of a flexibilityprogram is to improve range of motion in the major muscle-tendon groups in accordance with individualized goals [4].For the majority of the aging population, the goals may not

2 Journal of Aging Research

be related to athletic performance, but rather performance offunctional abilities in activities of daily living. Nevertheless,there is relatively little research on the potential benefits offlexibility-specific training interventions for this populationin that context. Despite the lack of research and no “knownhealth benefits” [5], again, there is still a tendency in theliterature to mention flexibility training as a presumed“component of fitness” and beneficial adjunct to other formsof exercise. Therefore, the purpose of this systematic reviewis to investigate the functional outcomes of flexibility specifictraining in older adults.

2. Methods

2.1. The Literature Search and Inclusion Criteria. A searchstrategy was developed, where all reasonable expressionsof the concepts of aging, flexibility, functional outcomes,and training interventions were considered (see Appendixfor a sample search strategy). A comprehensive electronicliterature search was conducted on five online databases:PubMed (NCBI; 1950-), Embase (OVID; 1974-), CINAHL(OVID & EBSCO; 1982-), Scopus (1823-), and SportDis-cus (EBSCO; 1800-). The literature was searched up toJanuary 2011. The final inclusion criteria for this paperwere (1) an original research article, (2) human subjects,(3) an intervention study, (4) flexibility training was anindependent intervention or was used as a control, (5) agedpopulation (mean age ≥ 65 years), and (6) the populationwas healthy but allowing for arthritis, osteoarthritis, andthose residing in assisted living (based on age and risk,not diseases or other medical conditions). For this paper,healthy was operationally defined as community-dwellingand assisted living with the health and function and cognitiveability to participate in light physical activity interventionsand complete physical function measures. Interventionstargeting specific chronic conditions (aside from arthritisand osteoarthritis) were excluded from review. Despite theiruse in flexibility training, tai chi- and yoga-based studieswere excluded from this paper because by nature they includestrength components. The electronic search yielded 4037citations. The citations and applicable electronic versionsof the article (where available) were downloaded to anonline research management system (RefWorks, Bethesda,MD, USA).

2.2. Screening. Two reviewers independently (RL, LS) eval-uated the articles for relevance using standard systematicreview methodology leading to further consideration of 22articles.

Two reviewers independently completed standardizeddata extraction forms for each level of screening. Three levelsof screening were utilized. Level 1 screening was based onarticle titles, Level 2 was based on the title and abstract, andLevel 3 was a full text screening. The articles that progressedthrough to Level 3 were retrieved electronically or manuallyvia the Canadian interlibrary system and were printedfrom electronic copy. Any cross-referenced articles from thereference section of Level 3 articles were hand-screened.

Disagreements regarding inclusion were resolved throughdiscussion with a third reviewer (DP).

2.3. Data Extraction. Data from the included studies wereextracted (Table 1) and organized by the target musclegroups of the flexibility interventions. Two reviewers com-pleted standardized data extraction forms. One reviewerperformed the data extraction for each paper assigned tothem and the extraction was verified by another reviewer.The reviewers were not blinded to the journal or the authornames when extracting information from the articles.

2.4. Level of Evidence. The approach used to establish thelevel and grade of evidence was consistent with Lau et al.[6] which provide predefined and objective criteria. Thus,the strength of the evidence was assessed for flexibilityinterventions and functional outcomes in older adults withrespect to general recommendations and appropriate dose.

2.5. Quality Assessment. Quality assessment of the includedstudies was also performed (Table 1). The Downs and Black[7] scale was selected to assess the quality of each study as it isappropriate to evaluate nonrandomized investigations, and itcontained the highest number of relevant items for the needsof this paper. However, as not all items were relevant to thevarious study types included in this paper, a modified versionof the checklist was employed for each of RCTs (randomizedcontrol trials), and non-RCTs study types. Thus, the qualityof each study was also established similar to the method ofGorber et al. [8] to include the most relevant componentsof the scoring tool. Therefore, a modified version of theDowns and Black checklist was used with the final checklistconsisting of 22 items with a maximum score of 24 points forthe studies of a RCT design; 22 items for non-RCT designswith a maximum score of 23; experimental single groupinterventions had a maximum score of 18 from 18 items;experimental single-group and single-session studies werebased on 14 items for a maximum score of 14. Higher scoresreflected a superior quality of investigation.

2.6. Integration of Findings. Due to the heterogeneity acrossstudy populations, methods used, and outcomes assessed, weconducted a narrative synthesis of the results.

3. Results

3.1. Description of Studies. The initial search yielded 4037articles. Twenty-two articles were ultimately included aftermeeting Level 3 inclusion criteria (Figure 1). Of the final 22articles, 18 were from electronic database searching, and 4were found by hand searching. Quality assessment indicatedthat the RCT studies (n = 13) were of good quality with anaverage score of 18 out of 24. The non-RCT studies (n = 6)had an average score of 14 out 23. An average score of 12out of 18 was assessed for the experimental single-groupstudies (n = 3). Fourteen articles were conducted in theUnited States [10–12, 14, 15, 17, 18, 20, 22, 25–29], whilethe remainder of the studies were from Japan [19], Brazil

Journal of Aging Research 3

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13/1

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4 Journal of Aging Research

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iffer

ence

betw

een

grou

psw

as“a

lmos

tsi

gnifi

can

t.”R

esp

onse

tim

eU

nch

ange

din

both

grou

ps.

Sen

sati

onN

oap

pare

nt

diff

eren

ces.

Th

eco

ntr

olgr

oup

lost

asm

alla

mou

nt

ofst

ren

gth

and

bala

nce

inju

st3

mon

ths,

even

thou

ghfl

exib

ility

impr

oved

.T

hes

ere

sult

ssu

gges

tth

atth

em

ore

com

preh

ensi

veth

eex

erci

sein

terv

enti

on,t

he

grea

ter

the

likel

ysc

ope

ofim

prov

emen

tin

frai

lty.

14/2

4

6 Journal of Aging Research

Ta

ble

1:C

onti

nu

ed.

Pu

blic

atio

nco

un

try/

stu

dyty

pe

Obj

ecti

vePo

pula

tion

Met

hod

sO

utc

omes

Com

men

tsan

dco

ncl

usi

ons

Qu

alit

y

Kin

get

al.2

000

[12]

.U

SA.

RC

T.Fo

cus

Maj

orm

usc

legr

oups

.

Toev

alu

ate

the

effec

tsof

two

diff

eren

tco

mm

un

ity-

base

dph

ysic

alac

tivi

tyre

gim

ens—

onon

eye

arph

ysic

alpe

rfor

man

ceou

tcom

es,

per

ceiv

edfu

nct

ion

ing

and

wel

l-be

ing

ina

sam

ple

ofco

mm

un

ity-

dwel

ling,

sede

nta

ryw

omen

and

men

.

n=

103

Age

:70±

4yr

Mal

es=

36,f

emal

es=

67 Incl

usi

oncr

iter

ia>

65yr

s,ab

sen

ceof

card

iova

scu

lar

dise

ase

orst

roke

,reg

ula

rly

acti

ven

om

ore

than

2x/w

eek

duri

ng

the

prec

edin

g6

mo,

free

ofm

usc

ulo

skel

etal

prob

lem

sth

atw

ould

prev

ent

part

icip

atio

nin

mod

erat

ele

vels

ofph

ysic

alac

tivi

ty.

Pre

-pos

t12

mon

th,6

mon

thin

teri

mas

sess

men

t2

exer

cise

clas

ses/

wee

kan

dh

ome

exer

cise

atle

ast

2w

k−1.

Cla

sses

one

hou

r,h

ome

exer

cise

built

up

to40

min

sess

ion

s.E

xper

imen

talg

rou

p(fi

tan

dfi

rm)

Pro

gres

sive

mod

erat

e-in

ten

sity

endu

ran

cean

dst

ren

gth

enin

gex

erci

ses.

5–10

min

war

m-u

p,40

–45

min

aero

bic

and

stre

ngt

htr

ain

ing

circ

uit

,5–1

0m

inco

ol-d

own

;ta

rget

hea

rtra

te60

–75%

HR

R.

Con

trol

grou

p(s

tret

chan

dfl

ex)

Stre

tch

ing

and

flex

ibili

tyex

erci

ses.

5–10

min

war

m-u

p,40

min

stre

tch

ing

sect

ion

,5–1

0m

inre

laxa

tion

exer

cise

s.St

retc

hin

gfo

rn

eck,

shou

lder

s,ba

ck,c

hes

t,w

aist

,ham

stri

ngs

,ca

lves

,an

dh

ands

.A

sses

smen

tsFu

ncti

onal

capa

city

/end

uran

ce:

Gra

ded

trea

dmill

exer

cise

test

(GX

T).

Stre

ngth

and

flexi

bilit

y:u

pper

body

stre

ngt

h(l

ift

and

reac

hta

sk),

low

erbo

dyst

ren

gth

(sit

tost

and)

,an

dfl

exib

ility

(sit

and

reac

hw

/Acc

ufl

ex1

sit

and

reac

hbo

x.Se

lf-ra

ted

phys

ical

perf

orm

ance

:ase

lf-e

ffica

cyqu

esti

onn

aire

.Pe

rcei

ved

func

tion

ing

and

wel

l-be

ing:

scal

esfr

omth

eM

edic

alO

utc

omes

Stu

dy(M

OS)

incl

.ph

ysic

alfu

nct

ion

ing,

bodi

lypa

in,

emot

ion

alw

ell-

bein

g,

(val

ues

repo

rted

sepa

rate

lyfo

rm

enan

dw

omen

for

each

grou

p).

Fun

ctio

nal

cap

acit

y/en

du

ran

ceSu

bmax

HR

:Fit

&Fi

rmh

adsi

gnifi

can

tly

grea

ter

impr

ovem

ent

vers

us

Stre

tch

&Fl

exSt

ren

gth

and

flex

ibil

ity

Lif

tan

dre

ach

task

:Fit

&Fi

rmh

adsi

gnifi

can

tly

grea

ter

upp

erbo

dyst

ren

gth

than

Stre

tch

&Fl

ex.

Sit-

to-s

tan

d:N

osi

gnifi

can

tre

sult

s.Si

t-an

d-re

ach

:Men

assi

gned

toSt

retc

h&

Flex

had

sign

ifica

ntl

ygr

eate

rin

crea

ses

than

men

inFi

t&

Firm

.No

stat

isti

cald

iffer

ence

inw

omen

,bu

ttr

end

for

grea

ter

impr

ovem

ent

for

wom

enin

Fit

&Fi

rmve

rsu

s.St

retc

h&

Flex

.Wom

enin

Fit

&Fi

rmh

adsi

gnifi

can

tly

grea

ter

incr

ease

sin

flex

ibili

tyat

12m

oth

anm

en.

Self

-rat

edp

hysi

calp

erfo

rman

ceSi

gnifi

can

tly

grea

ter

incr

ease

sin

wal

kin

gdi

stan

cean

dse

lf-e

ffica

cyfo

rh

eavy

lifti

ng

inFi

t&

Firm

than

inSt

retc

h&

Flex

.P

erce

ived

fun

ctio

nin

gan

dw

ell-

bei

ng

On

lypa

insc

ale

had

sign

ifica

ntl

ygr

eate

reff

ects

for

Stre

tch

&Fl

ex(a

lso

stat

isti

cally

sign

ifica

nt

wit

hin

grou

p)th

anFi

t&

Firm

.

Com

mu

nit

y-ba

sed

phys

ical

acti

vity

regi

men

sfo

cusi

ng

onm

oder

ate-

inte

nsi

tyen

dura

nce

and

stre

ngt

hen

ing

exer

cise

sor

flex

ibili

tyex

erci

ses

can

bede

liver

edth

rou

gha

com

bin

atio

nof

form

ats

that

resu

ltin

impr

ovem

ents

inim

port

ant

fun

ctio

nal

and

qual

ity

oflif

eou

tcom

es.

21/2

4

Journal of Aging Research 7

Ta

ble

1:C

onti

nu

ed.

Pu

blic

atio

nco

un

try/

stu

dyty

pe

Obj

ecti

vePo

pula

tion

Met

hod

sO

utc

omes

Com

men

tsan

dco

ncl

usi

ons

Qu

alit

y

ener

gy/f

atig

ue,

slee

ppr

oble

ms,

sen

seof

mas

tery

,an

dse

lf-e

stee

m.

An

alys

isA

NO

VA

,AN

CO

VA

,MA

NC

OV

A,

Tuke

y’s

stu

den

tize

dra

nge

test

,an

dle

ast-

squ

ares

mea

ns

proc

edu

re.

Laz

owsk

iet

al.1

999

[13]

.C

anad

a.R

CT.

Focu

sM

ajor

mu

scle

grou

ps.

Toev

alu

ate

grou

pex

erci

sepr

ogra

ms

inlo

ng-

term

care

vers

us.

flex

ibili

tyco

ntr

olgr

oup.

n=

68.

Age

:80±

0.9

yr.

11m

ale,

57fe

mal

e.Fu

nct

ion

alFi

tnes

sfo

rlo

ng-

term

care

prog

ram

(FFL

TC

)gr

oup

n=

36.

7m

ale,

29fe

mal

e.R

ange

ofm

otio

n(R

OM

)gr

oup

n=

32.

2m

ale,

30fe

mal

e.R

esid

ents

offi

velo

ng-

term

care

inst

itu

tion

s(>

3m

onth

)In

clu

sion

crit

eria

No

rece

nt

card

iova

scu

lar

even

ts,

un

con

trol

led

hig

hB

P,re

cen

tfr

actu

re,t

otal

blin

dnes

s,or

deaf

nes

s.A

bilit

yto

stan

dw

ith

min

imal

assi

stan

ce.

Wal

kin

gde

vice

san

dw

hee

lch

airs

allo

wed

.

Pre

-pos

t4

mo

Inte

rven

tion

FFLT

Cgr

oup

45m

in,3

wk−

1

war

mu

p/st

retc

hin

g(5

min

),w

alki

ng

(15

min

),pr

ogre

ssiv

eu

pper

and

low

erbo

dyst

ren

gth

enin

g(1

0m

in),

bala

nce

,an

dco

oldo

wn

stre

tch

ing

(5m

in).

Con

trol

grou

pSe

ated

ran

geof

mot

ion

grou

pvo

cale

xerc

ises

,wor

d/m

emor

yga

mes

,ran

geof

mot

ion

exer

cise

s(fi

nge

rs,h

ands

,arm

s,kn

ees,

ankl

es),

and

rela

xati

onex

erci

ses.

Ass

essm

ents

Mob

ility

-tim

edu

p-an

d-go

(TU

G).

Fun

ctio

nal

bala

nce

-Ber

gSc

ale.

Stai

rcl

imbi

ng

pow

er.

Fun

ctio

nal

abili

ty-f

un

ctio

nal

inde

pen

den

cem

easu

re(F

IM).

Flex

ibili

ty-M

odifi

edsi

tan

dre

ach

test

.sh

ould

erfl

exio

n.

Isom

etri

cst

ren

gth

:elb

owfl

exio

n,

shou

lder

abdu

ctio

n,k

nee

exte

nsi

on,h

ipab

duct

ion

/add

uct

ion

.gr

ipst

ren

gth

.Is

oton

icSt

ren

gth

:kn

eeex

ten

sors

.

86%

and

79%

com

plia

nce

RO

Msc

ored

low

eron

seve

ral

mea

sure

sat

base

line.

Con

side

rabl

eva

riab

ility

wit

hin

all

con

diti

ons

onal

lmea

sure

s.FF

LTC

led

tosi

gnifi

can

tim

prov

emen

tsin

mob

ility

,bal

ance

,fl

exib

ility

,an

dva

riou

sm

easu

res

ofst

ren

gth

.Fu

nct

ion

alca

paci

tyw

asu

nch

ange

din

the

FFLT

Cgr

oup

and

decr

ease

din

the

RO

Mgr

oup.

No

chan

gein

grip

stre

ngt

h,g

ait

spee

dan

dst

air-

clim

bin

gpo

wer

for

eith

er,g

rou

p.R

OM

(con

trol

).In

crea

sed

TU

Gti

me.

No

chan

gein

bala

nce

orlo

wer

body

flex

ibili

ty.

Non

-sig

nifi

can

t3.

5%ch

ange

insh

ould

erfl

exio

nR

OM

.21

%in

crea

sein

shou

lder

abdu

ctio

nst

ren

gth

.D

eclin

ein

isot

onic

leg

and

hip

stre

ngt

h.

Th

eFF

LTC

issu

itab

lefo

rlo

ng-

term

care

resi

den

ts,

feas

ible

for

staff

tode

liver

,an

dlo

w-c

ost.

Mos

tim

port

antl

y,fu

nct

ion

alou

tcom

escl

earl

ysu

per

ior

tose

ated

RO

Mpr

ogra

m.

RO

Mm

ayim

prov

esh

ould

er-a

bdu

ctio

nst

ren

gth

,bu

tw

illn

otpr

even

tde

clin

esin

low

erbo

dyst

ren

gth

,m

obili

ty,a

nd

bala

nce

.

21/2

4

8 Journal of Aging Research

Ta

ble

1:C

onti

nu

ed.

Pu

blic

atio

nco

un

try/

stu

dyty

pe

Obj

ecti

vePo

pula

tion

Met

hod

sO

utc

omes

Com

men

tsan

dco

ncl

usi

ons

Qu

alit

y

Stan

zian

oet

al.2

009

[14]

.U

SA.

RC

T.Fo

cus

Maj

orm

usc

legr

oups

.

Toex

amin

eim

pact

ofan

acti

ve-

assi

sted

(AA

)fl

exib

ility

prog

ram

onR

OM

and

fun

ctio

nal

perf

orm

ance

vari

able

sin

olde

rpe

rson

sliv

ing

ina

resi

den

tial

reti

rem

ent

com

mu

nit

y(R

RC

).

n=

17.

Age

:88±

5.4

yr.

Exp

erim

enta

lgro

up

n=

8.90±

4.5

yr.

1m

ale,

7fe

mal

e.C

ontr

olgr

oup

n=

9.88±

6.2

yr.

3m

ale,

6fe

mal

e.In

clu

sion

crit

eria

Livi

ng

inan

RR

C,a

bilit

yto

sit

upr

igh

tin

ach

air

for

30m

in(n

oak

ath

isia

,n

euro

logi

cal,

oros

teop

orot

iclim

itat

ion

s).

Pre

-pos

t8

wks

2w

k−1

Exp

erim

enta

lgro

up

10st

retc

hes

:bac

ksc

ratc

h(s

hou

lder

flex

ion

/abd

uct

ion

),st

andi

ng

thig

h(h

iphy

pere

xten

sion

),si

delu

nge

(hip

abdu

ctio

n),

over

hea

dba

ck(s

hou

lder

hyp

erfl

exio

n),

over

hea

dsi

de(l

ater

altr

un

kfl

exio

n),

cros

sch

est

(hor

izon

tals

hou

lder

addu

ctio

n),

seat

edtr

un

ktw

ist

(tru

nk

rota

tion

),se

ated

ham

stri

ng

(tru

nk/

hip

flex

ion

),an

dse

ated

calf

(dor

sifl

exio

n).

10re

peti

tion

s,4-

5s

each

.C

ontr

olgr

oup

Art

san

dcr

afts

clas

sw

ith

limit

edph

ysic

alex

erti

on.

Ass

essm

ent

Con

duct

ed1

wk

befo

rean

daf

ter

trai

nin

gpe

riod

.Fl

exib

ility

:ba

cksc

ratc

hte

st(B

S).

Mod

ified

chai

rsi

tan

dre

ach

test

(SR

).Su

pin

ekn

eeex

ten

sion

test

(KE

).M

odifi

edto

talb

ody

rota

tion

test

(BR

).St

ren

gth

/pow

er:

30-s

ecch

air

stan

d(C

S).

Mod

ified

ram

ppo

wer

test

(MR

PT

).30

-sec

arm

curl

(AC

).G

allo

nju

gsh

elft

est

(GJS

T).

Mob

ility

:50

-foo

tga

itsp

eed

test

(GS)

.8-

foot

tim

edu

pan

dgo

(UG

).A

nal

ysis

AN

CO

VA

n=

13Fl

exib

ilit

ySi

gnifi

can

tin

crea

ses

inR

OM

mad

eby

exp

erim

enta

lgro

up

for

all

mea

sure

sbu

tle

ftsi

deB

San

dri

ght

side

SR.

Con

trol

grou

psh

owed

no

chan

gein

any

flex

ibili

tym

easu

rebu

ta

sign

ifica

nt

loss

inR

OM

for

righ

t-si

dekn

eeex

ten

sion

.Fu

nct

ion

alit

yE

xper

imen

talg

rou

psi

gnifi

can

tly

impr

oved

CS

and

MR

PT,

wh

ileco

ntr

olh

adsi

gnifi

can

tde

clin

es.

Exp

erim

enta

lgro

up

sign

ifica

ntl

yim

prov

edin

AC

and

the

GJS

T,w

hile

con

trol

had

no

chan

ge.

Exp

erim

enta

lgro

up

redu

ced

tim

eta

ken

toco

mpl

ete

the

UG

and

GS.

Eig

ht

wee

ksof

AA

stre

tch

ing

may

bean

effec

tive

inte

rven

tion

for

impr

ovin

gR

OM

,mob

ility

,an

dfu

nct

ion

alp

ower

for

olde

rpe

rson

sliv

ing

ina

RR

C.

Dat

apr

ovid

ecl

ear

link

betw

een

flex

ibili

tyan

dfu

nct

ion

alpe

rfor

man

cein

olde

rp

erso

ns

and

supp

ort

the

incl

usi

onof

flex

ibili

tytr

ain

ing

inin

terv

enti

ons

desi

gned

toin

crea

sein

depe

nde

nce

inol

der

pers

ons.

16/2

4

Journal of Aging Research 9

Ta

ble

1:C

onti

nu

ed.

Pu

blic

atio

nco

un

try/

stu

dyty

pe

Obj

ecti

vePo

pula

tion

Met

hod

sO

utc

omes

Com

men

tsan

dco

ncl

usi

ons

Qu

alit

y

Raa

bet

al.1

988

[15]

.U

SA.

Non

-RC

T.Fo

cus

Maj

orm

usc

legr

oups

.

Exa

min

eth

eab

ility

ofw

eigh

ted

and

non

wei

ghte

dex

erci

ses

toin

crea

sefl

exib

ility

inol

der

adu

lts

inth

eh

ip,s

hou

lder

,w

rist

,an

kle,

and

nec

k.

n=

46.

Fem

ale.

Exp

erim

enta

lgro

ups

Exe

rcis

e(n

ow

eigh

ts,

EN

).n=

16.

70±

3.9

yr.

Exe

rcis

e(w

ith

wei

ghts

,EW

).n=

17.

70±

3.2

yr.

Con

trol

grou

pN

oex

erci

se.

n=

1371±

8.1

yr.

Hea

lthy

,act

ive

olde

rad

ult

s.

Pre

-pos

t25

wks

.E

xerc

ise

pro

gram

60m

in,3

days

/wee

k;5–

10m

intr

eadm

illw

arm

-up;

10m

inae

robi

csat

65%

HR

max

;25

–30

min

wh

ole

body

stre

ngt

han

dfl

exib

ility

exer

cise

s;10

–15

mon

cool

-dow

n.

Exe

rcis

esin

volv

edac

tive

and

pass

ive

stre

tch

ing

hel

dfo

r20

s,sl

owci

rclin

gm

otio

ns

for

RO

M,

and

repe

titi

vem

ovem

ents

for

exam

ple,

leg

curl

s.E

Wh

adgr

adu

alin

trod

uct

ion

ofw

rist

and

ankl

ew

eigh

ts.

Ass

essm

ents

Shou

lder

flex

ion

and

abdu

ctio

n.

Nec

kro

tati

on.

Wri

stfl

exio

n/e

xten

sion

.A

nkl

efl

exio

n/e

xten

sion

.H

ipfl

exio

n.

An

alys

isTw

o-w

ayA

NO

VA

,Du

nn

-pla

nn

edco

mpa

riso

ns

wit

htw

oco

ntr

asts

,on

e-an

dtw

o-ta

iled

t-te

sts.

Flex

ibili

tyim

prov

edsi

gnifi

can

tly

for

exer

cise

grou

psin

ankl

epl

anta

rfl

exio

n,s

hou

lder

flex

ion

abdu

ctio

n,

and

cerv

ical

rota

tion

toth

ele

ft.

Hip

flex

ion

(refl

ecti

ng

ham

stri

ng

flex

ibili

ty)

incr

ease

dfo

ral

lgro

ups

,w

ith

no

betw

een

-gro

ups

diff

eren

ces.

Th

eex

erci

sew

ith

no

wei

ghts

grou

psh

adn

earl

y2.

5xgr

eate

rin

crea

sein

RO

Mth

anex

erci

sew

ith

wei

ghts

for

shou

lder

abdu

ctio

n.N

oot

her

flex

ibili

tyco

mpa

riso

ns

inth

eex

erci

segr

oups

wer

esi

gnifi

can

t.N

ofu

nct

ion

alou

tcom

es.

Exe

rcis

eca

nin

crea

sefl

exib

ility

inh

ealt

hy,o

lder

wom

enby

impr

ovin

gsh

ould

erfl

exio

nan

dab

duct

ion

,an

kle

plan

tar

flex

ion

,an

dce

rvic

alro

tati

on.

For

shou

lder

abdu

ctio

n,a

non

wei

ghte

dex

erci

sepr

ogra

mca

npr

odu

cegr

eate

rfl

exib

ility

gain

sin

olde

rad

ult

sth

ana

wei

ghte

dex

erci

sepr

ogra

m,a

nd

shou

ldbe

con

side

red

iffl

exib

ility

isth

epr

imar

ygo

al.

13/2

3

10 Journal of Aging Research

Ta

ble

1:C

onti

nu

ed.

Pu

blic

atio

nco

un

try/

stu

dyty

pe

Obj

ecti

vePo

pula

tion

Met

hod

sO

utc

omes

Com

men

tsan

dco

ncl

usi

ons

Qu

alit

y

Bir

det

al.2

009

[16]

.A

ust

ralia

.R

ando

miz

edC

ross

over

.Tr

ia.l.

Focu

sM

ajor

mu

scle

grou

ps.

Tode

term

ine

the

effec

tof

com

mu

nit

y-ba

sed

resi

stan

ce-

vers

us

flex

ibili

ty-t

rain

ing

prog

ram

son

bala

nce

and

rela

ted

mea

sure

s.

n=

32.

Age

:mea

n67

yr.

Mal

es=

18,

Fem

ales

=14

.Se

den

tary

.In

clu

sion

crit

eria

No

his

tory

ofst

roke

orot

her

neu

rolo

gica

ldi

seas

eor

curr

ent

diab

etes

,ca

rdio

vasc

ula

rdi

seas

e,or

un

con

trol

led

hype

rten

sion

.No

use

ofw

alki

ng

aids

.

Pre

-pos

t16

wks

,4w

kw

ash

out,

16w

ks(c

ross

over

).In

terv

enti

onB

oth

grou

psh

ad3

sess

ion

s. wk−

1

for

16w

ks,t

hen

4w

kw

ash

out,

then

swit

ched

toot

her

grou

pfo

r16

wks

.R

esis

tan

cetr

ain

ing

(RT

)2-

3se

tsof

10–1

2re

ps.

Flex

ibil

ity

trai

nin

g(F

T)

40–4

5m

inw

ith

16–2

0st

retc

hes

;tw

ost

retc

hes

for

each

of:

ham

stri

ngs

,qu

adri

ceps

,bac

k,an

dch

est.

Ass

essm

ents

Bal

ance

,for

cepl

ate.

Tim

edu

p-an

d-go

.10

tim

essi

t-to

-sta

nd.

Step

test

.Lo

wer

limb

stre

ngt

h(r

igh

tan

dle

ftkn

ee-fl

exio

nan

dex

ten

sion

)w

ith

anis

okin

etic

dyn

amom

eter

.A

nal

ysis

Rep

eate

dm

easu

res

AN

OV

A

Low

erlim

bst

ren

gth

incr

ease

dsi

gnifi

can

tly

inth

eR

Tgr

oup,

but

not

inth

efl

exib

ility

grou

pan

dth

ere

was

asi

gnifi

can

tdi

ffer

ence

betw

een

the

two

grou

ps.

Sign

ifica

nt

impr

ovem

ents

wer

ese

enin

both

grou

psfo

rti

med

up-

and-

go,

10ti

mes

sit-

to-s

tan

d,an

dst

epte

st.

Sign

ifica

nt

impr

ovem

ents

inm

edia

l-la

tera

lsw

ayra

nge

wer

ese

enin

the

flex

ibili

tygr

oup

only

.Si

gnifi

can

tde

crea

ses

insw

ayve

loci

tyw

ere

seen

inbo

thco

ndi

tion

s.

Sign

ifica

nt

impr

ovem

ents

inba

lan

cep

erfo

rman

cew

ere

ach

ieve

dw

ith

both

resi

stan

ce-t

rain

ing

and

stan

din

gfl

exib

ility

-tra

inin

gpr

ogra

ms

inh

ealt

hyu

ntr

ain

edol

der

adu

lts.

Flex

ibili

typr

ogra

mdi

din

corp

orat

eso

me

degr

eeof

bala

nce

trai

nin

gin

the

nat

ure

ofth

efl

exib

ility

task

s.

19/2

4

Journal of Aging Research 11

Ta

ble

1:C

onti

nu

ed.

Pu

blic

atio

nco

un

try/

stu

dyty

pe

Obj

ecti

vePo

pula

tion

Met

hod

sO

utc

omes

Com

men

tsan

dco

ncl

usi

ons

Qu

alit

y

Swan

ket

al.2

003

[17]

.U

SA.

Non

-RC

T.Fo

cus

Maj

orm

usc

legr

oups

.

Tode

term

ine

the

effec

tsof

addi

ng

mod

est

han

dan

dan

kle

wei

ghts

tow

hol

e-bo

dyst

retc

hin

gex

erci

seon

RO

M.

n=

43.

Age

:55–

83yr

.B

ody

Rec

all(

BR

).n=

18.

68±

5.6

yr;8

mal

e,10

fem

ale.

BR

+W

eigh

ts.

n=

14.

68±

3.1

yr.

4m

ale,

10fe

mal

e.C

ontr

ol.

n=

11.

69±

6.5

yr.

1m

ale,

10fe

mal

e.Pa

rtic

ipan

tsof

body

reca

llol

der

adu

ltlo

win

ten

sity

flex

ibili

typr

ogra

m.

Incl

usi

oncr

iter

iaN

oov

ert

dise

ase

oran

yse

vere

lylim

itin

gor

thop

aedi

cpr

oble

ms

Pre

-pos

t10

wks

.In

terv

enti

onSu

perv

ised

.B

R=

pain

-fre

e,sm

ooth

,rhy

thm

icw

hol

e-bo

dym

ovem

ents

.Tr

ain

ing

grou

p1

(BR

)60

min

ute

s,3

wk−

1.

Trai

nin

ggr

oup

2(B

R+

W)

60m

inu

tes,

3w

k−1w

ith

grad

ual

prog

ress

ion

ofan

kle

wei

ghts

and

ban

dex

erci

ses.

Con

trol

grou

pN

ode

scri

ptio

n.A

sses

smen

tR

OM

(gon

iom

eter

)fo

rn

eck

(lef

tan

dri

ght

rota

tion

),h

ip(fl

exio

nan

dex

ten

sion

),sh

ould

er(fl

exio

nan

dab

duct

ion

),kn

ee(e

xten

sion

and

flex

ion

),an

dan

kle

(pla

nta

ran

ddo

rsifl

exio

n).

An

alys

isA

NC

OV

A,L

even

e’s

test

ofeq

ual

ity.

Tuke

yH

ones

tly

Sign

ifica

nt

Diff

eren

cete

st,

P=≤

0.01

.

(pre

valu

esn

otgi

ven

).Si

gnifi

can

tdi

ffer

ence

sfo

un

dfo

r6

of10

RO

Mm

easu

res:

cerv

ical

rota

tion

(lef

tan

dri

ght)

,hip

exte

nsi

on,a

nkl

efl

exio

n/e

xten

sion

and

shou

lder

flex

ion

,for

both

BR

and

BR

+W

inco

mpa

riso

nto

con

trol

BR

+W

show

edsi

gnifi

can

tly

grea

ter

incr

ease

sin

4of

6m

easu

res

that

show

edsi

gnifi

can

tch

ange

:cer

vica

lro

tati

on(l

eft

and

righ

t),h

ipex

ten

sion

,an

dan

kle

dors

iflex

ion

vers

us

BR

.

Fou

nd

that

the

addi

tion

ofw

eigh

tsen

han

ced

effec

tive

nes

sof

stre

tch

ing

exer

cise

.It

islik

ely

that

apo

siti

veeff

ect

was

not

edfo

r2

reas

ons:

incr

ease

dre

sist

ance

duri

ng

exer

cise

mov

emen

tan

dex

erci

ses

wer

ep

erfo

rmed

thro

ugh

full

RO

M.

Itse

ems

plau

sibl

eto

hypo

thes

ize

that

grea

ter

effec

tsw

ould

besh

own

byad

diti

onof

wei

ghts

tost

retc

hin

gro

uti

nes

for

nu

rsin

gh

ome

clie

nts

orfr

ee-l

ivin

g,ot

her

wis

ese

den

tary

elde

rly.

14/2

3

12 Journal of Aging Research

Ta

ble

1:C

onti

nu

ed.

Pu

blic

atio

nco

un

try/

stu

dyty

pe

Obj

ecti

vePo

pula

tion

Met

hod

sO

utc

omes

Com

men

tsan

dco

ncl

usi

ons

Qu

alit

y

Ale

xan

der

etal

.200

1[1

8].

USA

.N

on-R

CT.

Focu

sM

ajor

mu

scle

grou

ps.

(1)

An

alyz

eth

ebi

omec

han

ics

ofri

sepe

rfor

man

cedu

rin

gch

air-

rise

task

sw

ith

vary

ing

task

dem

and

inm

ore

disa

bled

olde

rad

ult

s.(2

)To

dete

rmin

ew

het

her

ast

ren

gth

-tra

inin

gpr

ogra

mm

igh

tim

prov

ech

air-

rise

succ

ess

and

alte

rch

air-

rise

stra

tegy

vers

us.

flex

ibili

tyco

ntr

ol.

n=

30(fi

nal

).Tr

ain

ing

Gro

up.

n=

16.

Age

:82±

6.0

yr.

4m

ale,

12fe

mal

e.C

ontr

olgr

oup.

n=

14.

Age

:84±

7.4

yr.

2m

ale,

12fe

mal

e.R

esid

ents

oflo

cal

hou

sin

gfa

cilit

y.In

clu

sion

crit

eria

>65

yr.

No

low

erex

trem

ity

hem

iple

gia

oram

puta

tion

s,bl

indn

ess,

acu

tein

flam

mat

ory

orin

fect

iou

sill

nes

s,an

dn

ode

men

tia.

Mu

stco

mpl

ete

the

easi

est

chai

r-ri

seta

sk.

Can

not

becu

rren

tly

invo

lved

info

rmal

exer

cise

.

Pre

-pos

t12

wks

.In

terv

enti

onR

esis

tan

cetr

ain

ing

1h

our/

day,

3da

ys. w

k−1

usi

ng

Hyd

raFi

tnes

shy

drau

liceq

uip

men

tfo

rlo

wer

body

exer

cise

.Als

ow

eigh

ted

chai

rri

sean

dw

eigh

ted

ankl

efl

exio

n/e

xten

sion

.C

ontr

olgr

oup

Part

icip

ated

inse

ries

ofse

ated

nec

k,tr

un

k,ar

m,l

eg,a

nd

foot

flex

ibili

tyex

erci

ses.

Ass

essm

ent

Seve

nch

air

rise

task

s,bi

omec

han

ics

ofta

sks

H=

usi

ng

han

dsN

H=

wit

hou

tu

sin

gh

ands

60/1

00/1

40ar

ese

ath

eigh

tsas

%of

floo

rto

knee

hei

ghts

).A

nal

ysis

Two-

way

AN

OV

A,r

epea

ted

mea

sure

sA

NO

VA

wit

hpa

irw

ise

post

hoc

com

pari

son

s(F

ish

er’s

PL

SD).

On

lytr

ain

ing

grou

pim

prov

edab

ility

toco

mpl

ete

the

mos

tdi

fficu

ltta

sks.

Con

trol

sm

ain

tain

edp

erfo

rman

ces

inge

ner

al,o

ne

ortw

ode

clin

ed.

On

lysi

gnifi

can

tde

crea

sew

asin

tota

lri

seti

me

for

both

grou

psat

H-1

00.

Cen

tre

ofP

ress

ure

(CO

P)

incr

ease

dsi

gnifi

can

tly

inbo

thgr

oups

inal

lta

sks

but

H-1

40(h

igh

est

seat

hei

ght)

.K

nee

torq

ues

incr

ease

dfo

rbo

thgr

oups

sign

ifica

ntl

yfo

rH

-100

,H-6

0,N

H-1

00,a

nd

NH

-100

-F.

Mea

nh

ipto

rqu

esin

crea

sed

sign

ifica

ntl

yin

con

trol

san

dde

crea

sed

sign

ifica

ntl

yin

trai

nin

ggr

oup

inH

-60.

Subt

le,y

etsi

gnifi

can

tch

ange

sca

nbe

dem

onst

rate

din

chai

r-ri

sep

erfo

rman

ceas

are

sult

ofco

ntr

olle

d,sh

ort-

term

resi

stan

cetr

ain

ing

prog

ram

.

15/2

3

Journal of Aging Research 13

Ta

ble

1:C

onti

nu

ed.

Pu

blic

atio

nco

un

try/

stu

dyty

pe

Obj

ecti

vePo

pula

tion

Met

hod

sO

utc

omes

Com

men

tsan

dco

ncl

usi

ons

Qu

alit

y

Take

shim

aet

al.2

007

[19]

.Ja

pan

.N

on-R

CT.

Focu

sM

ajor

mu

scle

grou

ps.

Toco

mpa

reth

eeff

ects

ofa

wal

kin

g-ba

sed

aero

bic

prog

ram

,aba

nd-

base

dre

sist

ance

prog

ram

,ast

retc

hin

g-fl

exib

ility

prog

ram

,a

cust

omiz

edba

lan

cepr

ogra

m,

and

aTa

iCh

ipr

ogra

mon

fun

ctio

nal

fitn

ess

ina

grou

pof

com

mu

nit

yol

der

adu

lts.

n=

117.

73±

6yr

.64

mal

e,49

fem

ale.

Aer

obic

(AE

R).

n=

13.

Res

ista

nce

(RE

S).

n=

17.

Bal

ance

(BA

L).

n=

15.F

lexi

bilit

y(F

LE

X).

n=

16.

TaiC

hi(

T-C

HI,

Yan

gSt

yle)

.n=

31.

Con

trol

(CO

N).

n=

25.

Hea

lthy

sede

nta

ry.

Incl

usi

oncr

iter

iaN

om

eds

for

hyp

erte

nsi

on,H

RT.

No

CH

D,n

ore

gula

rph

ysic

alac

tivi

ty.

Pre

-pos

t12

wks

.In

terv

enti

onSu

perv

ised

2da

ysw

k−1

(RE

S,B

AL

,FL

EX

,T-C

HI)

3da

ysp

erw

k(A

ER

).A

llh

ad10

–15

min

war

m-u

p60

–70

min

ofsp

ecifi

cex

erci

se:

AE

R-O

utd

oor

wal

kin

gR

ES-

Pro

gres

sive

elas

tic

ban

dex

erci

ses

for

allm

ajor

mu

scle

grou

psB

AL-

Eye

sop

en/c

lose

d,ex

erci

seon

floo

r,on

foam

mat

sFL

EX

-15

stat

icst

retc

hes

for

upp

eran

dlo

wer

body

(15–

20s

each

).T

-CH

I-st

anda

rdiz

ed24

form

s.A

sses

smen

tsFu

nct

ion

alFi

tnes

s.30

sar

mcu

rlte

st.

30s

chai

rst

and

tim

e.8

Ftti

med

up-

and-

go.

back

scra

tch

test

.ch

air

sit

and

reac

hte

st.

12m

inw

alk

test

.A

nal

ysis

AN

OV

A.

Wilk

’scr

iter

ion

.K

olom

ogor

ov-S

mir

nov

test

.

Impr

ovem

ent

inca

rdio

resp

irat

ory

fitn

ess

(12

min

wal

k)w

aslim

ited

toA

ER

(16%

)R

ES,

BA

L,an

dT

-CH

I,re

sult

edin

impr

ovem

ents

inu

pper

and

low

erbo

dyst

ren

gth

and

bala

nce

/agi

lity.

RE

Ssh

owed

grea

test

upp

erbo

dyst

ren

gth

impr

ovem

ent

(31%

).B

AL

show

edgr

eate

stlo

wer

body

stre

ngt

him

prov

emen

t(4

0%).

Bal

ance

/agi

lity

was

sim

ilar

acro

ssR

ES,

BA

L,a

nd

T-C

HI

(10%

).Fu

nct

ion

alre

ach

,sim

ilar

impr

ovem

ents

for

AE

R(1

3%),

BA

L(1

6%),

RE

S(1

5%).

No

sign

ifica

nt

chan

ges

inei

ther

FLE

Xor

CO

Non

any

mea

sure

.

Itis

reco

mm

ende

dth

atol

der

adu

lts

part

icip

ate

ina

wel

l-ro

un

ded

exer

cise

prog

ram

vs.s

ingl

em

ode.

RE

S,B

AL

,an

dTA

IC

HI

cros

sdo

mai

ns

not

spec

ifica

llyta

rget

edin

thei

rde

sign

.A

ER

nec

essi

tate

sae

robi

c-sp

ecifi

cac

tivi

tyto

impr

ove

card

iore

spir

ator

yfi

tnes

s.W

ith

FLE

X,l

ack

ofim

prov

emen

tsu

gges

tsth

atfu

rth

erst

udy

isn

eede

dto

expl

ore

the

effec

tof

flex

ibili

tyex

erci

setr

ain

ing

inol

der

adu

lts.

18/2

3

14 Journal of Aging Research

Ta

ble

1:C

onti

nu

ed.

Pu

blic

atio

nco

un

try/

stu

dyty

pe

Obj

ecti

vePo

pula

tion

Met

hod

sO

utc

omes

Com

men

tsan

dco

ncl

usi

ons

Qu

alit

y

Eri

ckso

net

al.2

011

[20]

.U

SA.

RC

T.Fo

cus

Maj

orm

usc

legr

oups

.

Toev

alu

ate

wh

eth

er1

year

ofex

erci

setr

ain

ing

incr

ease

sth

esi

zeof

the

hip

poca

mpu

san

dim

prov

essp

atia

lmem

ory

usi

ng

mod

erat

e-in

ten

sity

aero

bic

exer

cise

vers

us

ast

retc

hin

gan

dto

nin

gex

erci

sepr

ogra

m.

n=

120.

Exp

erim

enta

l(ex

p).

n=

60.

Age

:68

yr.

16m

ale,

44fe

mal

e.C

ontr

ol(c

on).

n=

60.A

ge:6

6yr

.24

mal

e,46

fem

ale.

Com

mu

nit

y-dw

ellin

g,se

den

tary

.In

clu

sion

crit

eria

Age

d55

–80

yr,n

ode

men

tia,

hea

lthy

less

than

30m

in.o

fPA

inla

st6

mo.

Bot

hE

XP

and

CO

Ngr

oups

incl

ude

dsa

me

5m

inof

stre

tch

ing,

both

befo

rean

daf

ter

exer

cise

.P

rogr

amla

sted

1ye

ar.

Aer

obic

exer

cise

con

dit

ion

(EX

P)

Pro

gres

sed

from

wal

kin

g10

min

at50

–60%

HR

Rm

axto

40m

inat

60–7

5%H

RR

max

byw

eek

7,th

enm

ain

tain

edu

nti

lpro

gram

fin

ish

ed.

Stre

tch

ing

and

ton

ing

con

trol

con

dit

ion

(CO

N)

4m

usc

leto

nin

gex

erci

ses,

2ba

lan

ceex

erci

ses,

one

yoga

sequ

ence

,an

don

eex

erci

seof

choi

ce.T

old

toex

erci

seat

RP

Eof

13–1

5on

20pt

Bor

gsc

ale.

Ass

essm

ents

VO

2m

axM

RI

for

hip

poca

mpa

lvol

um

e.C

ompu

ter-

base

dsp

atia

lmem

ory

task

.A

nal

ysis

Rep

eate

dm

easu

res

AN

OV

A.

t-te

sts.

EX

Pgr

oup

VO

2m

axin

crea

sed

7.78

%w

hile

CO

Nin

crea

sed

1.11

%.

EX

Pgr

oup

had

sign

ifica

nt

grou

p×

tim

ein

tera

ctio

nfo

rin

crea

sed

hip

poca

mpu

ssi

ze(l

eft

+2.

12%

,ri

ght

+1.

97%

),w

hile

CO

Ngr

oup

decl

ined

(lef

t−1

.4%

,rig

ht−1

.43%

).

Gre

ater

incr

ease

sin

aero

bic

fitn

ess

wer

eas

soci

ated

wit

hgr

eate

rin

crea

sed

inh

ippo

cam

palv

olu

me,

sugg

esti

ng

that

larg

erch

ange

sin

fitn

ess

tran

slat

eto

larg

erch

ange

sin

volu

me.

Hig

her

aero

bic

fitn

ess

leve

lsat

base

line

wer

eas

soci

ated

wit

hbe

tter

spat

ialm

emor

y.A

erob

icex

erci

se-i

ndu

ced

incr

ease

sin

BD

NF

are

sele

ctiv

ely

rela

ted

toth

ech

ange

sin

ante

rior

hip

poca

mpa

lvol

um

e.Lo

ssof

hip

poca

mpa

lvol

um

ein

late

adu

lth

ood

isn

otin

evit

able

and

can

bere

vers

edw

ith

mod

erat

e-in

ten

sity

exer

cise

.

19/2

4

Journal of Aging Research 15

Ta

ble

1:C

onti

nu

ed.

Pu

blic

atio

nco

un

try/

stu

dyty

pe

Obj

ecti

vePo

pula

tion

Met

hod

sO

utc

omes

Com

men

tsan

dco

ncl

usi

ons

Qu

alit

y

Cec

elie

tal

.200

9[2

1].

Turk

ey.

Non

-RC

T.Fo

cus

Maj

orm

usc

legr

oups

.

Tode

term

ine

ifpe

rfor

min

gre

gula

rR

OM

exer

cise

sh

ada

ben

efici

aleff

ect

onth

eba

lan

ce,

fun

ctio

nal

acti

vity

,an

dfl

exib

ility

ofel

derl

ysu

bjec

ts.

n=

46.

Age

:73

yr.

3m

ales

,43

fem

ales

.G

rou

p1.

n=

25.

Age

:74±

5.15

yr.

21fe

mal

e;3

mal

es.

Res

th

ome

resi

den

ts.

Gro

up

2(c

ontr

ol).

n=

21.

Age

:72±

4.13

yr.

Fem

ale.

Inpa

tien

tcl

inic

pati

ents

,an

dse

den

tary

hou

sew

ives

.In

clu

sion

crit

eria>

65yr

.A

ble

toam

bula

tew

ith

out

assi

stiv

ede

vice

.In

depe

nde

nt

inac

tivi

ties

ofda

ilyliv

ing.

Pre

-pos

t;4

mon

th.

Inte

rven

tion

Supe

rvis

edR

OM

exer

cise

s.Su

pin

epo

siti

onw

ith

10re

peti

tion

sof

each

upp

eran

dlo

wer

extr

emit

yjo

ints

.3

wk−

1,2

0m

in.

Flex

ibil

ity

Late

ralt

run

kfl

exio

n(r

igh

tan

dle

ft)

dist

ance

betw

een

mid

dle

fin

ger

atre

stan

din

max

late

ralfl

exio

n.

An

teri

ortr

un

kfl

exio

n:d

ista

nce

from

mid

dle

fin

ger

tip

toth

egr

oun

d.B

alan

ceSh

arpe

ned

Rom

berg

(SR

)te

st.

On

e-le

gged

stan

cete

st(O

LST

).B

oth

test

sp

erfo

rmed

wit

hey

esop

enth

encl

osed

.Fu

nct

ion

alac

tivi

ty.

30m

Wal

kin

gT

ime.

Fun

ctio

nal

reac

hte

st.

An

alys

isM

ann

-Wh

itn

eyU

test

.

Sign

ifica

nt

incr

ease

inG

rou

p1

vers

us

2in

left

(10.

76to

13.3

2cm

,P=

0.03

5)an

dri

ght

(10.

47to

12.8

8cm

,P=

0.44

)la

tera

lflex

ion

.No

chan

gein

ante

rior

flex

ion

(8.6

6to

8.24

cm)

30m

wal

kti

me

decr

ease

dsi

gnifi

can

tly

from

28.1

4to

20s

(P=

0.00

1)in

Gro

up

1.Fu

nct

ion

alre

ach

incr

ease

dsi

gnifi

can

tly

from

15.9

5to

19.6

cm(P=.0

14).

No

sign

ifica

nt

diff

eren

cein

bala

nce

test

s.

Au

thor

sst

ated

that

part

icip

atin

gin

daily

flex

ibili

tygr

oup

exer

cise

incr

ease

sR

OM

and

cau

ses

som

eim

prov

emen

tin

bala

nce

.W

hen

com

pare

dto

ara

ndo

mly

sele

cted

hos

pita

lap

plie

dgr

oup,

the

rest

hom

egr

oup

has

bett

erba

lan

ce,

tru

nk

flex

ibili

tyan

dfu

nct

ion

alab

ility

.

11.5

/23

16 Journal of Aging Research

Ta

ble

1:C

onti

nu

ed.

Pu

blic

atio

nco

un

try/

stu

dyty

pe

Obj

ecti

vePo

pula

tion

Met

hod

sO

utc

omes

Com

men

tsan

dco

ncl

usi

ons

Qu

alit

y

Ch

rist

ian

sen

2008

[22]

.U

SA.

RC

T.Fo

cus

Hip

san

dan

kles

.

Toex

amin

eth

eeff

ects

ofa

hip

and

ankl

est

atic

stre

tch

ing

prog

ram

onfr

eely

chos

enga

itsp

eed

ofh

ealt

hy,

com

mu

nit

y-dw

ellin

gol

der

peop

len

otac

tive

inex

erci

se.

n=

37.

Age

:72±

4.7

yr.

Inte

rven

tion

Gro

up

.n=

18.A

ge:7

2±

4.7

yr.

3m

ale,

15fe

mal

e.C

ontr

olgr

oup.

n=

19.

Age

:72±

5.0

yr.

5m

ale,

14fe

mal

e.In

depe

nde

ntl

yliv

ing.

Incl

usi

oncr

iter

iaIn

desi

red

age

ran

ge,

hea

lthy

,no

join

tor

mu

scu

losk

elet

alpa

inth

atlim

ited

mov

emen

tin

past

mon

th,n

odi

agn

osed

gait

orba

lan

cedi

sord

er,n

ofa

llsh

isto

ry,h

asn

otpa

rtic

ipat

edin

form

alex

erci

sedu

rin

gth

epr

evio

us

6m

onth

,an

dh

asn

otu

sed

anas

sist

ive

devi

cefo

rw

alki

ng.

Pre

-pos

t8

wee

ks.

Inte

rven

tion

grou

pH

ipan

dan

kle

stre

tch

ing.

2st

atic

stre

tch

esh

eld

for

45se

con

dsan

dre

pea

ted

3ti

mes

alte

rnat

ing

side

s;to

tal9

min

ute

s(5

40s)

/ses

sion

.St

retc

hes

are

stan

din

gca

lfst

retc

han

dst

andi

ng

hip

flex

orst

retc

h.

Con

trol

grou

pE

nsu

red

no

chan

ges

incu

rren

tph

ysic

alac

tivi

ty.

Ass

essm

ents

Pass

ive

RO

M:g

onio

met

ric

mea

sure

men

tsof

hip

(hip

exte

nsi

onba

sed

onT

hom

aste

stpo

siti

on)

and

ankl

e.G

ait:

shoe

son

;tw

ow

alki

ng

spee

ds.

An

alys

isIn

depe

nde

nt

tte

sts

orch

i-sq

uar

ete

sts,

ICC

mod

el2

and

form

1,2-

fact

orre

pea

ted

mea

sure

sA

NO

VA

,sep

arat

ere

pea

ted-

mea

sure

sA

NO

VA

,pa

ired

tte

sts,

and

Bon

ferr

oni

adju

stm

ent.

85%

com

plia

nce

Gai

t:si

gnifi

can

tin

crea

sein

free

ly-c

hos

enga

itsp

eed

for

inte

rven

tion

grou

p(1

.23

to1.

30m

s−1,+

0.7m

s−1,a

nd

P=

0.01

6)ve

rsu

s.co

ntr

ol(n

och

ange

).jo

intm

otio

n:pe

akh

ipex

ten

sion

and

knee

flex

ion

incr

ease

dsi

gnifi

can

tly

(59.

7to

66.5◦ )

inin

terv

enti

ongr

oup,

wit

hn

och

ange

inco

ntr

ol(5

6.2

to56

.1◦ )

.Si

gnifi

can

tin

crea

sein

inte

rven

tion

grou

p(7

.8to

11.3◦ )

for

pass

ive

dors

iflex

ion

,wit

hn

och

ange

inco

ntr

ol.

Oth

er:N

osi

gnifi

can

tch

ange

sin

stri

dele

ngt

hor

join

tan

gula

rdi

spla

cem

ent.

Evid

ence

ispr

ovid

edfr

omth

ere

sult

sth

atjo

int

mot

ion

isa

mod

ifiab

leim

pair

men

tth

atca

nbe

effec

tive

lyta

rget

edfo

rol

der

peo

ple

wit

hsi

mpl

e,st

atic

stre

tch

ing

hom

e-ba

sed

inte

rven

tion

.

19/2

4

Journal of Aging Research 17

Ta

ble

1:C

onti

nu

ed.

Pu

blic

atio

nco

un

try/

stu

dyty

pe

Obj

ecti

vePo

pula

tion

Met

hod

sO

utc

omes

Com

men

tsan

dco

ncl

usi

ons

Qu

alit

y

Cri

stop

olis

kiet

al.

2009

[23]

.B

razi

l.R

CT.

Focu

sH

ips

and

ankl

es.

Tode

term

ine

wh

eth

era

4w

ksu

per

vise

dst

retc

hin

gpr

ogra

mfo

rlo

wer

limbs

alte

rsga

itki

nem

atic

sin

aged

popu

lati

on.

n=

28.

Fem

ale.

Exp

erim

enta

lGro

up.

n=

12.

Age

:66±

4.2

y.r

Con

trol

Gro

up.

n=

8.A

ge:6

5±

2.9

yr.

Ch

arac

teri

stic

sC

omm

un

ity

dwel

ling.

Incl

usi

oncr

iter

iaH

ealt

hy,n

oga

itpe

rfor

man

celim

itat

ion

s.

Pre

-pos

t4

wks

.In

terv

enti

onE

xper

imen

talg

rou

p.3

sess

ion

s. wk−

1.

Supe

rvis

ed.

5m

inw

alki

ng

war

m-u

p.H

ipex

ten

sor/

flex

orm

usc

les,

ankl

epl

anta

rfl

exor

mu

scle

s.St

atic

stre

tch

es,6

0s

each

,4ti

mes

.C

ontr

oln

oac

tivi

ty.

Ass

essm

ent

Stat

icR

OM

ofh

ipex

ten

sion

and

flex

ion

and

ankl

edo

rsifl

exio

nby

phot

ogra

phy.

Gai

tp

erfo

rman

ceA

nal

ysis

Rep

eate

dm

easu

res

AN

OV

A,

un

ivar

iate

anal

ysis

,pos

th

ocSc

heff

e.

Stat

icra

nge

ofm

otio

nch

ange

dsi

gnifi

can

tly

(P<

0.05

)in

both

hip

and

ankl

ejo

ints

for

the

expe

rim

enta

lgr

oup,

no

chan

gein

the

con

trol

grou

p.H

ipex

ten

sion

(73

to91

◦ ).

Hip

un

iart

icu

lar

flex

ors

(6.3

to2.

0◦).

Hip

biar

ticu

lar

flex

ors

(7.0

to2.

7◦).

Pla

nta

rfl

exor

ampl

itu

de(3

9to

48◦ )

.E

xper

imen

talg

rou

psh

owed

incr

ease

dst

eple

ngt

h,h

igh

erve

loci

ty,

and

redu

ced

dou

ble

supp

ort

tim

eaf

ter-

trai

nin

g.

Supe

rvis

edst

retc

hin

gpr

ogra

mis

effec

tive

toal

ter

an

um

ber

ofga

itva

riab

les.

Age

dpa

rtic

ipan

tsdi

spla

yed

gait

para

met

ers

wh

ich

wer

esi

mila

rto

thos

eof

you

ng

adu

lts.

17/2

4

18 Journal of Aging Research

Ta

ble

1:C

onti

nu

ed.

Pu

blic

atio

nco

un

try/

stu

dyty

pe

Obj

ecti

vePo

pula

tion

Met

hod

sO

utc

omes

Com

men

tsan

dco

ncl

usi

ons

Qu

alit

y

Bat

ista

etal

.200

9[2

4].

Bra

zil.

Exp

erim

enta

l(P

re-p

ost

wit

hin

subj

ects

).Fo

cus

Ham

stri

ngs

.

Tode

term

ine

ifan

acti

vest

retc

hin

gpr

ogra

min

crea

ses

knee

-flex

orto

rqu

ean

dfl

exib

ility

,an

tago

nis

tic

torq

ue,

and

fun

ctio

nal

mob

ility

inol

der

adu

lts,

and

wh

eth

erth

epo

ssib

lead

apta

tion

sre

mai

naf

ter

inte

rven

tion

.

n=

12.

Sex:

fem

ale.

Age

:68±

6.4

yr.

Part

icip

ants

inge

riat

ric

revi

taliz

atio

npr

ogra

mfo

rat

leas

t12

mon

th.

Incl

usi

oncr

iter

ia>

60–8

0yr

s,n

ova

scu

lar,

infl

amm

ator

yor

low

er-l

imb

mu

scu

losk

elet

aldi

sord

ers.

No

un

con

trol

led

hyp

erte

nsi

onFl

exib

ility

defi

cit≥2

0◦.

4w

ksw

ith

out

stre

tch

ing

(A1)

follo

wed

by4

wks

ofst

retc

hin

gin

terv

enti

on(B

),fo

llow

edby

4w

eeks

wit

hou

tst

retc

hin

g(A

2).

Part

icip

ants

wer

eow

nco

ntr

ols

(A1)

.Fl

exib

ilit

yin

terv

enti

on(B

)2

wk−

1;4

wks

.St

andi

ng

infr

ont

ofta

ble,

ther

apis

tal

ign

edsp

ine

wit

hba

r,pa

rtic

ipan

tfl

exed

knee

san

dtr

un

ku

nti

lhan

dsre

ach

edta

ble.

Th

enex

ten

dkn

eean

dti

ltp

elvi

san

teri

orly

tom

axpa

inle

sste

nsi

onH

eld

for

60s,

retu

rned

tost

andi

ng

for

30s.

Rep

eate

d7

tim

es(7×

60=

420

s).

Ass

essm

ents

Kn

eeex

ten

sion

RO

Mde

fici

t(g

onio

met

er).

Isok

inet

icto

rqu

eof

knee

flex

ors

and

exte

nso

rs.

Tim

edU

p-an

d-G

o(T

UG

),fu

nct

ion

alca

paci

ty.

An

alys

isR

epea

ted

one-

way

anal

ysis

ofva

rian

ce.

Stu

den

t’sN

ewm

an-K

euls

test

.

Sign

ifica

nt

decr

ease

inkn

eeex

ten

sion

defi

cit

afte

rin

terv

enti

on(2

4.1◦

to14

.1◦ ,

P=

0.00

01),

but

not

com

plet

ely

mai

nta

ined

afte

r4

wks

(18.

8◦).

TU

Gp

erfo

rman

ceim

prov

ed(8

.4to

7.2

s,P<

0.05

)an

dre

mai

ned

aten

dof

prog

ram

(7.6

s).

Sign

ifica

nt

incr

ease

inco

nce

ntr

ican

dec

cen

tric

torq

ue

ofkn

eefl

exor

san

dex

ten

sors

.

Th

ekn

eefl

exor

stre

tch

ing

prog

ram

was

effec

tive

inin

crea

sin

gth

efl

exib

ility

ofth

ism

usc

legr

oup,

incr

easi

ng

knee

-flex

oran

dex

ten

sor

torq

ue

and

impr

ovin

gfu

nct

ion

alm

obili

tyin

olde

rad

ult

s.M

ost

impr

ovem

ents

last

edat

leas

t4

wks

afte

rth

est

retc

hin

gce

ased

.Th

ein

crea

sein

knee

RO

Mis

prob

ably

are

sult

ofad

apta

tion

inth

eco

nn

ecti

veti

ssu

eca

use

daf

ter

the

knee

-flex

orpr

ogra

m.

13/1

8

Journal of Aging Research 19

Ta

ble

1:C

onti

nu

ed.

Pu

blic

atio

nco

un

try/

stu

dyty

pe

Obj

ecti

vePo

pula

tion

Met

hod

sO

utc

omes

Com

men

tsan

dco

ncl

usi

ons

Qu

alit

y

Joh

nso

net

al.2

007

[25]

.U

SA.

Exp

erim

enta

l(P

re-p

ost

wit

hin

subj

ects

).Fo

cus

Cal

ves.

Toin

vest

igat

eth

eeff

ects

ofa

stat

icca

lfM

TU

stre

tch

ing

prog

ram

onan

kle

dors

iflex

ion

RO

Min

hea

lthy

adu

ltw

omen

65ye

ars

and

olde

r.

n=

13.

Age

:84±

4.7

yr.

Fem

ale.

Incl

usi

oncr

iter

ia>

65yr

,hea

lthy

.N

oev

iden

ceof

low

erex

trem

ity

dysf

un

ctio

n(a

sses

sed

byvi

sual

obse

rvat

ion

ofga

it).

Less

than

10◦

ofpa

ssiv

ean

kle

dors

iflex

ion

RO

M.

Fun

ctio

nal

lyin

depe

nde

nt.

Pre

-pos

t,6

wks

.N

oco

ntr

olgr

oup.

Inte

rven

tion

Supe

rvis

edst

retc

hin

gof

left

and

righ

tca

lfm

usc

lete

ndo

nu

nit

(MT

U).

Stan

din

gw

ith

shoe

son

,pla

ced

one

foot

infr

ont

ofot

her

inco

mfo

rtab

lest

eppi

ng

stan

cew

ith

han

dson

chai

r.Le

aned

forw

ard

onfr

ont

leg

un

til

stre

tch

felt

inre

arle

g.H

eld

for

60s

and

rep

eate

d4x

/leg

,on

ceda

ily,5

days

wk−

1fo

r6

wks

.A

sses

smen

tPa

ssiv

ean

kle

dors

iflex

ion

RO

Mby

gon

iom

etry

.M

easu

red

prio

rto

stre

tch

ing

prot

ocol

and

3da

ysaf

ter-

prot

ocol

.Po

stte

stin

gre

sear

cher

blin

dto

pret

esti

ng

data

.A

nal

ysis

Pair

edt-

test

.

Dor

sifl

exio

nR

OM

incr

ease

dsi

gnifi

can

tly

from

−11.

1◦to

1.2◦

(P<

0.00

1).

A6-

wk

stre

tch

ing

prot

ocol

sign

ifica

ntl

yim

prov

edan

kle

dors

iflex

ion

RO

Min

elde

rly

fem

ales

.Th

eR

OM

impr

ovem

ents

wer

em

ain

tain

ed3

days

afte

rth

ela

stda

y.W

ere

able

tode

mon

stra

tea

last

ing,

orpl

asti

cch

ange

inca

lfM

TU

pass

ive

RO

M.

10/1

8

20 Journal of Aging Research

Ta

ble

1:C

onti

nu

ed.

Pu

blic

atio

nco

un

try/

stu

dyty

pe

Obj

ecti

vePo

pula

tion

Met

hod

sO

utc

omes

Com

men

tsan

dco

ncl

usi

ons

Qu

alit

y

Gaj

dosi

ket

al.2

005

[26]

.U

SA.

RC

T.Fo

cus

Cal

ves.

(1)

Toex

amin

eth

eeff

ects

ofan

eigh

t-w

eek

stre

tch

ing

exer

cise

prog

ram

onca

lfm

usc

lele

ngt

h,a

nd

onth

eir

len

gth

exte

nsi

bilit

yan

dpa

ssiv

ere

sist

ive

forc

epr

oper

ties

for

olde

rw

omen

wit

hlim

ited

dors

iflex

ion

RO

M.

(2)

Toex

amin

eth

ein

flu

ence

ofth

est

retc

hin

gpr

ogra

mon

thre

efu

nct

ion

alte

sts.

n=

19.

Age

:65–

89yr

.Fe

mal

e.St

retc

hin

ggr

oup

n=

10.

Age

:73±

6.8

yr.

Con

trol

Gro

up.

n=

9.75±

8.3

yr.

Com

mu

nit

y-dw

ellin

g.In

clu

sion

crit

eria

Act

ive

dors

iflex

ion

≤10◦

.H

adab

ility

tore

lax

calf

mu

scle

san

dti

bial

isan

teri

ordu

rin

gpa

ssiv

em

ovem

ents

ofan

kle.

No

his

tory

ofor

thop

aedi

cor

neu

rolo

gica

ldi

sord

ers.

Min

imal

lyto

mod

erat

ely

acti

ve.

Pre

-pos

t8

wks

.St

retc

hin

ggr

oup

Hel

dst

atic

stre

tch

for

15s,

10re

pet

itio

ns

(tot

al15

0s)

3x/w

kfo

r8

wks

.C

ontr

olgr

oup

Did

not

exer

cise

.A

sses

smen

ts(M

easu

red

bare

foot

).Fu

nct

ion

alT

imed

agili

tyco

urs

e(m

odifi

cati

onof

tim

edu

p-an

d-go

).T

imed

10m

wal

k.St

andi

ng

forw

ard

fun

ctio

nal

reac

h.

Pas

sive

Kin

-Com

ankl

e-fo

otap

para

tus

(dor

sifl

exio

n)

Dor

sifl

exio

nra

nge

ofm

otio

n.

Pass

ive-

elec

tric

ener

gy(E

MG

).Pa

ssiv

ere

sist

ive

forc

es.

An

alys

isU

niv

aria

teA

NO

VA

,tw

o-w

ayM

AN

OV

A,P

illai

’sTr

ace,

two-

way

AN

OV

Afo

rre

pea

ted

mea

sure

s,an

don

e-w

ayA

NO

VA

s.

Stre

tch

ing

grou

psi

gnifi

can

tly

incr

ease

dm

axim

alpa

ssiv

edo

rsifl

exio

nan

gle

(11.

1to

16.2◦ ,

P<

0.00

1)an

dfu

llst

retc

hR

OM

(37.

1to

50.0◦ ,P=

0.00

5).N

osi

gnifi

can

tch

ange

sin

con

trol

grou

p.St

retc

hin

ggr

oup

show

edsi

gnifi

can

tim

prov

emen

tin

tim

edag

ility

cou

rse

(18.

26to

16.8

8s,P=

0.00

8)an

d10

mw

alk

(6.4

4to

5.99

s,P=

0.03

0).

No

chan

gein

con

trol

grou

psp

eed.

No

chan

gein

fun

ctio

nal

reac

hte

stfo

rei

ther

grou

p.St

retc

hin

ggr

oup

incr

ease

dbo

thab

sorb

edpa

ssiv

e-el

asti

cen

ergy

and

reta

ined

pass

ive-

elec

tric

ener

gy.

MV

C:S

tret

chin

ggr

oup

incr

ease

s14

%,w

hile

con

trol

grou

pin

crea

sed

3.5%

(bot

hn

onsi

gnifi

can

t).

An

8-w

eek

stre

tch

ing

prog

ram

for

shor

tca

lfm

usc

les

ofol

der

wom

enin

crea

sed

the

max

imal

DF

RO

Mw

hic

hin

dica

ted

incr

ease

dle

ngt

hof

the

calf

mu

scle

s.T

he

stre

tch

ing

prog

ram

also

incr

ease

dth

ele

ngt

hex

ten

sibi

lity,

pass

ive

resi

stiv

efo

rces

and

stor

edan

dre

tain

edpa

ssiv

eel

asti

cen

ergy

ofth

eca

lfm

usc

les.

Th

ese

adap

tati

ons

corr

esp

ond

wit

hde

crea

sed

agili

tyco

urs

ean

d10

mw

alk

tim

es.

19/2

4

Journal of Aging Research 21

Ta

ble

1:C

onti

nu

ed.

Pu

blic

atio

nco

un

try/

stu

dyty

pe

Obj

ecti

vePo

pula

tion

Met

hod

sO

utc

omes

Com

men

tsan

dco

ncl

usi

ons

Qu

alit

y

Pett

yet

al.1

999

[27]

.U

SA.

Tim

e-se

ries

,qu

asi-

expe

rim

enta

l.Fo

cus

Cal

ves.

(1)

Toex

amin

eth

ere

lati

onsh

ipbe

twee

nm

axim

um

ankl

edo

rsifl

exio

nR

OM

and

anin

divi

dual

’sab

ility

tom

ove

the

tru

nk

post

erio

rly

wit

hfi

xed

BO

S.(2

)To

exam

ine

inte

rven

tion

desi

gned

toin

crea

sega

stro

cnem

ius

len

gth

onm

axim

alan

kle

DF

RO

Man

dth

eab

ility

tom

ove

post

erio

rly

wit

hfi

xed

BO

S.(3

)To

exam

ine

the

con

trib

uti

ons

ofm

axim

um

ankl

eD

FR

OM

,age

,an

dh

eigh

tto

perf

orm

ance

ofvo

litio

nal

post

erio

rtr

un

km

ovem

ent.

n=

7.82±

4.5

yr.

4m

ale,

3fe

mal

e.Fr

omau

dien

ceat

reti

rem

ent

com

mu

nit

yle

ctu

re.

Exc

lusi

oncr

iter

iaA

nycu

rren

tn

euro

logi

cal

sym

ptom

s,ta

kin

gan

ym

edic

atio

ns

that

mig

ht

affec

tba

lan

ce,

any

visu

alpr

oble

ms

inte

rfer

ing

wit

hda

ilyfu

nct

ion

,sig

nifi

can

tpa

indu

rin

gba

ckw

ard

lean

test

.In

clu

sion

crit

eria

>65

yr,n

ogr

eate

rth

an0◦

ankl

eD

FR

OM

,at

leas

t90

◦of

shou

lder

flex

ion

and

0◦of

elbo

wex

ten

sion

,ab

ility

tost

and

wit

hou

tex

tern

alsu

ppor

tfo

r2

min

and

per

form

Bac

kwar

dLe

anTe

stpr

oper

ly,

and

not

curr

entl

yre

ceiv

ing

phys

ical

ther

apy.

Inte

rven

tion

4w

kst

retc

hin

gpr

ogra

m:

gast

rocs

stre

tch

ing

in“s

tep-

stan

din

g”po

siti

on;p

oin

tof

stre

tch

hel

dfo

r30

sfo

llow

edby

15s

rest

;4re

peti

tion

spe

rbo

dypa

rt,r

epea

ted

twic

ep

erda

y.A

sses

smen

tsM

axim

alan

kle

dors

iflex

ion

(kn

eeex

ten

ded)

.B

ackw

ard

Lean

Test

(bar

efoo

t).

An

alys

isPe

arso

npr

odu

ctm

omen

t.co

rrel

atio

nco

effici

ent.

Pair

edt

test

.M

ult

iple

regr

essi

onan

alys

is.

Mea

npr

etes

tD

FR

OM

:−5.

9◦±

2.5◦

incr

ease

dto

0.5◦±

2.9◦

(sig

nifi

can

tm

ean

chan

geof

6.4◦±

2.2◦

)B

ackw

ard

Lean

pre-

test

:5.2±

3.5

cmin

crea

sed

to9.

3±

3.6

cm(s

ign

ifica

nt

mea

nch

ange

of4.

1±

2.2

cm).

Th

eB

ackw

ard

Lean

test

prov

edu

sefu

lfor

asse

ssin

gch

ange

sin

dyn

amic

post

ura

lco

ntr

olin

apo

ster

ior

dire

ctio

n.

Th

ep

osit

ive

corr

elat

ion

betw

een

max

imal

ankl

eD

FR

OM

and

dist

ance

ofpo

ster

ior

hor

izon

talt

run

kex

curs

ion

duri

ng

Bac

kwar

dLe

anm

aybe

rela

ted

toth

ebi

omec

han

ical

requ

irem

ents

ofth

eB

Lte

st.

Subj

ects

wh

op

erfo

rmed

anex

erci

sepr

ogra

mde

sign

edto

len

gth

enth

ega

stro

csol

eus

mu

scle

sde

mon

stra

ted

incr

ease

dra

nge

ofm

axim

alan

kle

DF

wit

hkn

eeex

ten

ded

and

impr

oved

abili

tyto

lean

back

war

dw

hile

mai

nta

inin

ga

stat

ion

ary

BO

S.T

he

sign

ifica

nt

incr

ease

inD

FR

OM

from

pret

est

topo

stte

stsu

ppor

tsth

eeffi

cacy

ofth

est

retc

hin

gpr

otoc

ol.

Asi

gnifi

can

tre

lati

onsh

ipex

ists

betw

een

the

degr

eeof

avai

labl

em

axim

alan

kle

DF

RO

Mw

ith

the

knee

sex

ten

ded

and

the

hor

izon

tal

dist

ance

anin

divi

dual

isab

leto

mov

eth

etr

un

kpo

ster

iorl

yw

hile

mai

nta

inin

ga

fixe

dB

OS.

22 Journal of Aging Research

Ta

ble

1:C

onti

nu

ed.

Pu

blic

atio

nco

un

try/

stu

dyty

pe

Obj

ecti

vePo

pula

tion

Met

hod

sO

utc

omes

Com

men

tsan

dco

ncl

usi

ons

Qu

alit

y

Ker

riga

net

al.2

003

[28]

.U

SA.

Dou

ble-

blin

dR

CT.

Focu

sH

ipfl

exor

s.

Tote

stth

eeff

ect

ofa

hip

flex

orst

retc

hin

gpr

ogra

mon

age-

rela

ted

gait

chan

ges

abou

tth

ean

kle.

n=

96.

Mal

es=

30.

Fem

ales

=66

.Tr

eatm

ent.

n=

47.

15m

ale,

32w

omen

.C

ontr

ol.

n=

49.

15m

en,3

4w

omen

.In

clu

sion

crit

eria

≥65

yrs

old,

hea

lthy

.

Pre

-pos

t10

wks

.P

roto

col

Hom

eex

erci

ses.

Bot

hgr

oups

perf

orm

edw

arm

-up

and

cool

-dow

n;3

0s

stre

tch

esal

tern

atin

glim

bsfo

r4

sets

/8st

retc

hes

into

tal.

2xpe

rda

y(a

ppro

xim

atel

y5

min

).Tr

eatm

entg

rou

pH

ipst

retc

hin

gex

erci

se.

Con

trol

grou

pD

elto

idst

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Journal of Aging Research 23

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24 Journal of Aging Research

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Journal of Aging Research 25

Electronic database search

Level 1 screening: title

Level 2 screening: title

Level 3 screening: full text

Final full text articles

10: not original article69: no intervention studied280: no flexibility intervention

5: subjects not healthy1: study not in english

32: flexibility not focus of intervention or control protocol6: no flexibility intervention2: not original article

Hand searching of referencesRelevant database articles

4: single-session studies

and abstract

n = 4037

n = 4037

n = 436

n = 62

n = 18

n = 22

n = 4

Excluded or duplicates (n = 3601)

Excluded (n = 374)

9: subjects not >65 yr

Excluded (n = 44)

+

Figure 1: Article Screening Flow Chart.

[23, 24], Turkey [21], Australia [9, 16], Taiwan [30], andCanada [13].

3.2. Population. The mean sample age was 74.1 years,ranging from 64 years [30] to 88.8 years [14]. Seven studiesincluded populations that were ≥80 years of age [10, 11, 13,14, 18, 25, 27]. The number of participants in the articlesof this paper ranged from 7 [27] to 132 [30]. There were atotal of 1127 participants, 841 of whom were female (75%),while 286 were male. Six studies were female only [15, 23–26, 29]. Twenty studies were based on community-dwellingpopulations, and two studies involved individuals residing inassisted-living facilities [10, 13].

3.3. Outcome Measures. Outcomes were measured usingflexibility measurements, physical ability tests, and question-naires. One study also used brain imaging for the purposesof identifying changes in hippocampal volume with training[20]. A common outcome measure was simply whetherthere was a change in range of motion usually assessed bygoniometry [15, 17, 20, 24–28, 30]. The inclusion of thesestudies in the review (although they reported no “functionaloutcome”) was to provide the data for the purpose ofdetermining whether older adults would, in fact, improverange of motion about different joints with various flexibilityexercise programs. Functional outcomes were operationallydefined as tests or measures designed to reflect abilities forvarious levels of daily activities and potentially related tomaintenance of independence of older adults. In general,

these tests assessed ability in a function that involved morethan a single fitness component (e.g., not just a strengthmeasure of a weight that could be lifted, but rather aperformance that may involve strength and power as wellas balance and agility). The most commonly used tests offunctional outcome were gait and various walking speeds[11, 13, 14, 19, 21, 22, 26], the sit-and-reach test [10, 12–14,19, 29], the sit-to-stand test [9, 12, 14, 16, 18, 19], functionalreach test [9, 10, 21, 26], step test [9, 16], timed up-and-go(TUG) [10, 13, 14, 16, 19, 24, 26], and Romberg test [11,21]. Other functional outcome measures were Berg balancescale [13], questionnaires [9, 12], peg board [11], red-light-green-light [11], Lequesne’s index of disability [30], thephysical performance test (PPT) [11], and the gallon jugshelf test [14]. Gait and walking speed proved to be morepositively affected by flexibility training than other outcomemeasures [14, 19, 21, 22, 26], although this was not entirelyconsistent [11, 13]. Several studies showed increases inflexibility-related outcomes, but lacked significant changes inother more applicable and generic measures of functionality.Only one study followed up on outcome maintenance afterthe postintervention measurements. This study found thatknee torque and timed up-and-go showed improvementscompared to the control group, which persisted for fourweeks after intervention [24].

In the sub-group containing eight studies of the very old(≥80 years), frail, and assisted-living populations [10, 11, 13,14, 18, 21, 25, 27], there were significant improvements seenin functional reach [21], sit-to-stand [10, 14] and 30 m walktimes [21], but no changes in the PPT [11] and mixed resultsfor flexibility, strength, balance, and TUG tests. As comparedto studies on less aged independently-living populations,the outcomes results of this sub-group were similar, exceptthat the more aged/dependent group had less consistentflexibility outcomes; there were some neutral outcomes andsome negative changes following flexibility training.

Six out of the 22 studies included several functionaloutcome measures and were considered most relevant tothis paper [11–14, 16, 19], and are individually reviewedherein. Four of the six conducted randomized control trials(RCT) [11–14], and only two studies reported sample sizesless than 68 participants. Brown et al. [11] conducted a 12-week RCT (n = 87), wherein the flexibility trained groupdemonstrated only flexibility measure improvements and nochange in functional outcomes. The measures included werevery practical and included the chair stand, picking up apenny, putting on and taking off a coat, and the Rombergbalance test. However, it should be noted that this studyalso showed minor strength and balance losses. In a oneyear RCT, King et al. [12], similarly, showed no change inmost functional outcomes in the flexibility trained group.Functional measures included lift-and-reach, sit-to-stand,sit-and-reach, self-rated physical performance, self-efficacyfor physical performance scale, and perceived functioningand well-being. There were only significant increases for thesit-and-reach test in men only (10.4 to 11.9 inches) anddecreases in self-rated daily bodily pain scores (by 7.3% forwomen and 9.4% for men). Lazowski et al. [13] conducted

26 Journal of Aging Research

a 16-week RCT (n = 68). Timed up-and-go increased(worsened) from 27 to 33 seconds, and no changes wereseen in any other functional measures or in the sit-and-reach test. Additional functional measures included strengthtests, Berg balance scale, self-paced and fast-paced walk tests,stair-climbing, and the functional independence measurefor functional capacity. Stanziano et al. [14] employed an8-week RCT (n = 17), where the experimental flexibilitygroup significantly improved in every measure: chair standrepetitions (11 to 13), modified ramp power (69 W to 86 W),arm curl repetitions (12.9 to 18.8), gallon jug shelf test(13.4 to 11.5 seconds), 8 foot timed up-and-go (8.7 to 7.6seconds), and 50 foot gait speed (13.9 to 12.3 seconds). Thestudy by Bird et al. [16] was a 32-week randomized cross-over design (n = 32) with 16 weeks spent in the flexibilitygroup. Four functional outcomes improved significantly forthe flexibility group: TUG (7.6 to 6.6 seconds), sit-to-stand(22.6 to 18.0 seconds), step test (13.5 to 17.6 steps), andmediolateral sway range (eyes open: 4.16 to 2.97 cm; eyesclosed: 6.87 to 5.64 cm). Strength was also tested, with noimprovement by the flexibility group. In a 12-week non-RCT(n = 117), Takeshima et al. [19] reported no improvementsfor the flexibility trained group in the 12-minute walk, armcurls, chair stand, TUG, functional reach, back scratch, andsit-and-reach. These six studies exemplify the mixed resultsof the functional outcome measures in this paper. Theyserve as a strong representation of the lack of consistencyof functional outcomes in the literature and therefore, anyspecific recommendation regarding type or frequency ofstretching exercises is premature.

Overall, seven of 22 studies demonstrated mostly positivefunctional outcomes [9, 10, 14, 16, 21, 23, 29], whilesix reported mostly negative functional results, that is, noimprovement in variables [11–13, 18, 19, 22]. Ten studiesshowed no functional outcome measures [15, 17, 20, 24–30]and only reported changes in flexibility and ROM (althoughthey purported to relate flexibility to function, and wereincluded for their results related to the ability of older adultsto improve flexibility). There were no obvious differencesbetween the characteristics of the studies with positive,negative, or no functional outcomes.

3.4. Intervention Characteristics. Twelve studies used flexibil-ity training as the sole intervention [10, 11, 14, 17, 21–27,29], four studies used flexibility training as a significant partof an intervention protocol [15, 16, 19, 30], five studies usedflexibility as a control group to compare with various otherexercise interventions [9, 11–13, 18, 20], and four studiesutilized flexibility exercises along with strength or aerobicexercise in the intervention protocol but in the controlgroup, the entire exercise protocol was flexibility exercises[9, 11, 13, 20]. The types of flexibility training methodsvaried from simple static stretches (19 studies) to differentproprioceptive neuromuscular facilitation (PNF) techniques(1 study). Passive static stretching was the most commonmethod used [9, 11–13, 16, 18–29], while passive staticstretching with added weights was used once [17], active-assisted (AA) was used twice [14, 30], active and passive

were used in conjunction once [15], contract-relax (CR)PNF was used once [30], contract-relax-agonist contract(CRAC) PNF was used once [30], and hold-relax-agonistcontract (HRAC) PNF was used once as well [30]. One studycompared multiple methods with each other [30]. Active-assisted stretching had positive and sometimes significantimprovements in several outcome measures as comparedto the inactive control group, but less significant than theimprovements seen with the PNF techniques [30]. Weightedflexibility exercises were similar to nonweighted exercises inone study [15], but significantly better than nonweightedexercises in another [17].

Thirteen studies involved whole body flexibility training[9–21], two focused on hips and calves [22, 23], one focusedon hamstrings [24], three focused on calves [25–27], onefocused on hip flexors [28], one focused on the trunk[29], and one study focused on the quadriceps muscles[30]. Whole body flexibility training showed some minor tosignificant increases in outcomes; however, most increaseswere seen in ROM and flexibility measures, per se, andnot in other functional outcome measures. These resultswere consistent with the overall effects of specific isolatedstretching interventions on outcome measures for the relatedspecific body parts.

The mean length of the included studies was 14.2 weeks,ranging from 4 weeks to one year [12, 20]. Results didnot differ significantly throughout the range of interventiondurations. In the three studies of at least 25 weeks in duration[12, 15, 20], no functional outcome measures were improvedother than flexibility and ROM. In the four studies withdurations of 6 weeks or less [23–25, 27] TUG improvedfrom 8.4 to 7.2 seconds [24], walking velocity increased 1.07to 1.22 m/s [23], and flexibility and ROM were improvedoverall.

The mean frequency was 4-exercise sessions per week,ranging from the lowest frequency of twice per week [9, 10,12, 22, 24] to 14x/week [27, 28]. Two studies did not reportexercise frequency [20, 22]. Some results from these studiesinclude a TUG time decrease from 8.4 to 7.2 seconds [24] anda no-change [10], sit-to-stand time decreased from 10.2 to9.2 seconds [9] and 9.3 to 7.9 seconds [10] and a no-change[12], a step test increased in reps from 16.5 to 20.2 [9], andan increase in freely chosen gait speed from 1.23 to 1.30 m/s[22]. The 5x/week and 14x/week studies did not includefunctional outcomes similar to the twice weekly studies. The3x/week studies included results such as an improved TUGtime from 7.6 to 6.6 seconds [16] and a worsening time from26.8 to 33.0 seconds [13], a functional reach improvementof 16.0 to 19.6 cm [21] and two no-changes [19, 26], a sit-to-stand improvement of 22.6 to 18.0 seconds [16], a steptest improvement of 13.5 to 17.6 repetitions [16], a 10 mwalk time improvement from 6.44 to 5.99 seconds [26], anda 30 m walk time improvement from 28.1 to 20.0 seconds[21]. Although limited in number, these results show thatthe frequency of the flexibility training interventions had nonoticeable differences compare with 2 and 3 times per week.

The mean flexibility exercise session time was 32 minutes,ranging from 30 seconds [29] to 85 minutes [19].

Journal of Aging Research 27

4. Discussion

There are currently scientific discussions regarding the utilityof stretching exercises which are regularly recommended andconducted as a part of preexercise protocols to reduce injuryand increase performance. Earlier reviews of stretching andflexibility have questioned their value in terms of injury pre-vention, delayed onset of muscle soreness, and improvementof performance [31, 32]. In fact, what occurs physiologicallywith stretching remains unknown [32]. Due to equivocalevidence thus far, the current American College of SportsMedicine’s guidelines for exercise testing and prescription[33] recommended the removal of static stretching as partof a warm-up routine for strength and power activities.Additionally, based on available evidence, the 2011 ACSMposition statement for guidance on prescribing exercise sug-gests performing flexibility after cardiorespiratory enduranceor resistance exercise for general fitness programs. Thisposition stand highlighted the need for further researchto ascertain the effects of various flexibility prescriptionsfor various activities and performance goals. From thepresent review, there is not enough consistent evidence tomake recommendations for any specific prescriptions oftype, frequency, duration, or length of program related toflexibility training; particularly no specific recommendationscan be made regarding the program or dose response offlexibility training to the focus of the present study, thetransfer of flexibility gains to functions of daily life, orability to live independently. A recent systematic review of106 articles relating the effects of pre-exercise acute-passivestatic stretching on maximal muscle performance provided74 methodologically sound studies providing 104 findings[34]. This paper showed that 50% of the 104 findingsreported significant reductions in task performances, andthe authors concluded that static muscle stretches totalingless than 45 s can be used in pre-exercise protocols withoutsignificant decrement to strength, power or speed type tasks;thus a conclusion was to recommend stretches held for atmaximum 45 s to avoid loss of strength. Shrier [35] hadalso previously reported the potential negative acute effectsof stretching on performance, but additionally reviewed theliterature regarding regular stretching on performance whichindicates that regular stretching improves force, jump height,and speed performance. Both reviews recommend furthersynthesis of the literature with respect to the effects of otherforms of stretching on various performance measures.

The difficulties of the ability of this paper to providea consensus on flexibility training prescription for healthyolder adults include the lack of well-conducted studiesfocused on flexibility in older adults and the lack ofconsistency in the flexibility protocols employed, functionaloutcomes measured, and functional results observed. Assuch, according to the criteria used to assess level of evidence,to recommend stretching/flexibility exercises as a routinecomponent of an exercise program for older adults toenhance health or functional abilities is Level 4, GradeC. The more influential studies in this paper (based onfocused flexibility protocols with clear functional outcomesand relatively large sample sizes) [11–14, 16, 19] showed very

comparable effects to the overall outcomes of the 26 studies,namely, an ambivalence in the value of flexibility training onfunctional outcomes that may be related to maintenance ofindependence in daily activities of older adults. Of these sixstudies, 5 were RCTs with an average quality assessment scoreof 18 out of 24. Only two of the six showed improvement inflexibility and functional outcomes ([14] 16/24; [16] 19/24).

In the sub-group (≥80 years), frail, and assisted-livingpopulations there were significant improvements seen infunctional reach, sit-to-stand, and 30 m walk times, butno changes in the PPT, and mixed results were observedfor flexibility, strength, balance, and TUG tests. This sub-group was similarly ambivalent in the role of flexibilitytraining with functional outcomes to the rest of the studypopulations, although this group had less consistency inthe flexibility-related outcome measures. Frequency andduration differences between studies showed no noticeabledifferences in outcomes. When different muscle groupswere targeted, the flexibility outcomes were expectedly fairlybody-part specific. Regarding the different flexibility trainingmethods, active-assisted (AA) stretching had positive andsometimes significant improvements in several outcomemeasures as compared to the inactive control group, butless significant than the improvements seen with the PNFtechniques. Weighted flexibility exercises were similar tononweighted exercises in one study, but significantly betterthan nonweighted exercises in another. One study showedACR-PNF to be much more effective than CR-PNF and staticstretching for both ROM and EMG activity. The overallresults point to PNF stretching being more effective thannon-PNF techniques for improving flexibility outcomes, butnot necessarily functional outcome measures.

While flexibility training interventions synthesized inthe present paper have been shown to increase flexibilityand joint ROM, no consistent increases in functional out-comes have been observed. Therefore, future studies shouldconsider the relationship that increased flexibility and jointROM have with functional outcomes to determine if theincreased flexibility is beneficial and worthwhile in termsof maintaining or increasing functional capacity for healthyolder adults. More research is also needed regarding the rela-tionships between outcome variables (i.e., how one variablesuch as functional reach would relate to another variable suchas the timed up-and-go) and on the relationships betweenoutcome measures and quality of life through self-reportedfunctioning/quality of life questionnaires to best determinethe applicability of the outcome measures.

Older adults are less concerned with high performancebenefits from increased flexibility and more focused on beingsafely active and safely performing activities of daily living[36]. Injury and fall prevention are also common motivesfor recommending flexibility programs to older adults.The 2011 ACSM position statement notes that flexibilitytraining may enhance postural stability and balance whencombined with resistance training; however, no consistentlink has been shown between regular flexibility exercise anda reduction of musculoskeletal injuries or delayed onset ofmuscle soreness [4]. However, despite the growing literaturedescribing the relationship of flexibility to injury risk in

28 Journal of Aging Research

younger populations [31], there is little research regardingolder adults.

5. Conclusions

This paper found that flexibility training interventions inolder adults are often effective at increasing joint range ofmotion in various joints, and various functional outcomescan be improved. However, due to the wide range ofintervention protocols, body parts studied, and functionalmeasurements, conclusive recommendations regarding flex-ibility training and functional outcomes for older adultsremain ungrounded. As such, a specific prescription of howlong to hold a stretch, how many repetitions of each stretch toconduct, and the type of stretches to do, is not determinableat this point. Because there is conflicting informationregarding both the relationship between flexibility traininginterventions and functional outcomes, and the relationshipbetween improved flexibility and daily functioning andhealth benefits have not been established, future researchstudies should attempt to address these issues.

While there is a lack of evidence to recommend stretchingroutines outside of a rehabilitative context, there is noadditional health or functional risk of including flexibilityexercises. As such, in light of increases in functional out-comes achieved by other exercise modes (balance, aerobicexercise, and strengthening exercises), stretching exercisescan be included as an adjunct to the above, but the currentliterature would indicate it would add little to the functionalbenefits of the other exercise modes. Of note, the evidence-based and expert consensus statements of “Physical ActivityGuidelines for Older Adults” of the US, the UK, Canada,and the World Health Organization (Global recommenda-tions) have not included flexibility as a component in therecommendations.

Appendix

See Table 2.

Abbreviations

ACSM: American College of Sports MedicineRCT: Randomized control trialTUG: Time-Up-and GoROM: Range of motionPNF: Proprioceptive neuromuscular facilitationCR-PNF: Contract-relax proprioceptive

neuromuscular facilitationEMG: ElectromyographyACR-PNF: Active assisted contract-relax

proprioceptive neuromuscular facilitation.

Conflict of Interests

All the authors declare that they have no conflict of interests.

Table 2: Sample electronic database search strategy.

Sample search strategy-PubMed-January 2011

(1) Aged 331 611

(2) Aging 236 732

(3) Ageing 247 317

(4) “Older age” 15 622

(5) “Older adult∗” 2 357

(6) Elderly 3352095

(7) Senior∗ 22 086

(8) “Senior citizens” 734

(9) (1 OR 2 OR 3 OR 4 OR 5 OR 6 OR 7 OR 8) 3505009

(10) “Muscle stretching exercises” [Mesh] 420

(11) “Pliability/physiology” [Mesh] 28

(12) “Range of motion, Articular/physiology” [Mesh] 8 786

(13) “Joint motion” 1 420

(14) “Joint movement” 722

(15) “Joint mobility” 888

(16) “Joint range” 491

(17) “Joint adhesion” 1 825

(18) “Joint articulation” 42

(19) “Muscle lengthening” 141

(20) “Muscle elongation” 35

(21) “Proprioceptive neuromuscular facilitation” 117

(22) “Isometric contraction” 12 414

(23) Yoga 1 483

(24) “Tai chi” 455

(25) Pilates 56

(26)(10 OR 11 OR 12 OR 13 OR 14 OR 15 OR 16 OR17 OR 18 OR 19 OR 20 OR 21 OR 22 OR 23 OR24 OR 25)

28 177

(27) Ability 455 298

(28) Mobility 94 157

(29) Frailty 2 112

(30) Disability 80 338

(31) Dependen ∗ 1066172

(32) Independen ∗ 560 960

(33) Reliance 8 424

(34) Living 818 389

(35) Institutionaliz ∗ 12 329

(36) “Nursing home” 13 615

(37) “Activities of daily living” 45 277

(38) “Independent activities of daily living” 3 979

(39) ADL 4 683

(40) IADL 1 147

(41) “Assisted living” 1 197

(42) “Long-term care” 25 605

(43) “Long-term care” 25 605

(44)(27 OR 28 OR 29 OR 30 OR 31 OR 32 OR 33 OR34 OR 35 OR 36 OR 37 OR 38 OR 39 OR 40 OR41 OR 42 OR 43)

2738402

Journal of Aging Research 29

Table 2: Continued.

Sample search strategy-PubMed-January 2011

(45) Control 2295628

(46) Treatment 6813000

(47) Modality 165 777

(48) Adjunct 25 544

(49) Component 289 484

(50) Group 1741947

(51) Subset 76 495

(52) Subset 446

(53) Subgroup 55 099

(54) Subgroup 2 358

(55) “Exercise” [Mesh] 52 144

(56) “Exercise prescription” 772

(57) “Exercise program∗” 3 376

(58) “Exercise treatment” 240

(59) “Exercise therapy” 20 527

(60) Activity 1731305

(61) “Physical activity” 37 516

(62) “Physical therapy” 38 673

(63) “Fitness program∗” 277

(64) Dance 2 274

(65) “Rhythmic exercise” 86

(66)(45 OR 46 OR 47 OR 48 OR 49 OR 50 OR 51 OR52 OR 53 OR 54 OR 55 OR 56 OR 57 OR 58 OR59 OR 60 OR 61 OR 62 OR 63 OR 64 OR 65)

9 702261

(67) (9 AND 26 AND 44 AND 66) 2 401(67 NOT child NOT children NOT cognit∗ NOT“alzheimer disease”

434

NOT depression NOT anxiety NOT post-surg∗

NOT postsurg∗

NOT surgery NOT surgical NOT cardiac NOTfracture∗ NOT arthroplasty

(68)NOT diabetes NOT diabetic NOT cancer NOTstroke NOT Parkinson∗

NOT “multiple sclerosis” NOT sclerosis NOTstenosis NOT memoryNOT mental NOT coronary NOT cerebral NOTdystrophy NOT polio

NOT fibromyalgia)

Authors’ Contributions

All authors have made substantial contributions to theconception and design of the present systematic review.L. Stathokostas coordinated the conduct of the systematicreview. L. Stathokostas and R. M. D. Little were involvedin the acquisition and analysis of data. All authors wereresponsible for the interpretation of data. All authors havebeen involved in drafting the paper. All authors read andapproved the final manuscript for publication.

Disclosure

D. H. P. Paterson is the research director of the Cana-dian Centre for Activity and Aging and is responsible for

evidence-based development of exercise programs for olderadults. Recently, DH was a coauthor of a systematic reviewwhich resulted in the modification and update of Canada’sPhysical Activity Guidelines for Older Adults submitted toIJBNPA in 2010. This paper showed that exercise inter-ventions in older adults are effective in maintaining orimproving functional abilities. However, it was identified thatless is known about the role of flexibility in the maintenanceor improvement of functional abilities. As such, the presentpaper was undertaken.

Acknowledgment

The authors gratefully acknowledge the assistance of MarisaSurmacz, Health Sciences librarian, University of WesternOntario.

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